Place, displacement, and health-seeking behaviour among the Ugandan Batwa: A qualitative study

Abstract

For many Indigenous Peoples, relationships to the land are inherent in identity and culture, and to all facets of health and wellbeing, physically, emotionally, psychologically, and spiritually. The Batwa are Indigenous Peoples of rural, southwest Uganda who have experienced tremendous social and economic upheaval, due to relatively recent forced displacement and land dispossession. This loss of physical connection to their ancestral lands has significantly impacted Batwa health, and also affected available healthcare options for Batwa. This exploratory study (1) identified and characterized factors that influence Batwa health-seeking behaviour, using acute gastrointestinal illness, a critical public health issue, as a focal point for analysis; and (2) explored possible intersections between the Batwa's connection to place-and displacement-and their health-seeking behaviour for acute gastrointestinal illness. Twenty focus group discussions, stratified by gender, were conducted in ten Batwa settlements in Kanungu District, Uganda and eleven semi-structured interviews were conducted with primary healthcare workers, community health coordinators, clinical officers, and development program coordinators. Qualitative data were thematically analyzed using a constant comparative method. Batwa identified several significant motivators to engage with Indigenous and/or biomedical forms of healthcare, including transition to life outside the forest and their reflections on health in the forest; 'intellectual access' to care and generational knowledge-sharing on the use of Indigenous medicines; and Batwa identity and way of life. These nuanced explanations for health-seeking behaviour underscore the significance of place-and displacement-to Batwa health and wellbeing, and its relationship to their health-seeking behaviour for acute gastrointestinal illness. As such, the results of this study can be used to inform healthcare practice and policy and support the development of a culturally- and contextually-appropriate healthcare system, as well as to reduce the burden of acute gastrointestinal illness among Batwa.

Fig 1. Visual representation of the intersectoral, interdisciplinary research team involved in this study.

Green = 10 partner communities in Kanungu District; Blue = Academic institutions in Canada, the United Kingdom, and Uganda; Orange = National-level, governmental organizations; Yellow = District-level, non-governmental stakeholders, including the Batwa Development Program of the U.S.-based non-profit organization, The Kellermann Foundation.

Fig 2. Qualitative data gathering procedures used in this study.

These procedures include twenty gender-stratified focus group discussions with ten Batwa communities and eleven semi-structured interviews with a variety of individuals in healthcare, as well as governmental and non-governmental organizations.

Fig 3. Visual synthesis of results from this research, indicating the role of place and displacement in Batwa health-seeking behaviour for acute gastrointestinal illness, as shared by participants.

The transition from a forest-based, hunting and gathering livelihood to an agricultural livelihood impacted availability of foods important for health and illness prevention; generational knowledge-sharing of Indigenous treatments for acute gastrointestinal illness; and Batwa cultural identity and way of life tied to the use of Indigenous treatment.